Laboratory technician Ruth Rutledge packages cerebrospinal fluid of three confirmed meningitis cases in Minnesota to send to the Centers for Disease Control and Prevention in Atlanta for further testing. Officials have tied the outbreak of rare fungal meningitis to steroid shots for back pain. (AP Photo/Hannah Foslien)

The number of Minnesota clinics told to contact patients about the risk of a nationwide fungal meningitis outbreak has expanded dramatically as federal health officials said two more medications from a Massachusetts pharmacy might be linked to infections.

The Minnesota Department of Health said Tuesday, Oct. 16, that 129 clinics in the state received injected drugs from New England Compounding Center that could pose a risk of meningitis or other infections.

Previously, state officials identified two clinics in the Twin Cities that had given more than 800 patients the one injected steroid medication linked to the outbreak.

Now, with federal officials warning about a much larger number of drugs, it's unclear how many more Minnesota patients will be notified, said Richard Danila, an epidemiologist with the health department.

"I wouldn't even venture a guess," Danila said. "I have no idea."

Minneapolis-based Fairview Health Services was in the process Tuesday of contacting about 250 patients, said spokesman Ryan Davenport.

Gillette Children's Specialty Healthcare in St. Paul was notifying an unspecified number of patients; Regions Hospital was contacting one patient.

Since the nationwide outbreak was first reported this month, health officials have been focused on one injected steroid medication often administered for back pain. As of Tuesday, use of that medication had been linked to 233 cases nationwide, including five in Minnesota. Fifteen deaths have been reported.

But officials now say two more of the company's products could carry a meningitis or an infection risk.

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As a result, the Food and Drug Administration late Monday called on medical professionals to follow-up with patients who received any injected product manufactured by the Massachusetts pharmacy after May 21, 2012.

The company produced and distributed about 1,200 products, a large percentage of which were administered by injection, the FDA said.

Gillette Children's Specialty Healthcare in St. Paul did not buy any of the three medications that have been highlighted by FDA, said Cate Pardo, a hospital spokeswoman. But an unspecified number of Gillette patients did receive an injected epidural medication from the pharmacy, also referred to as NECC.

"Because the FDA is recommending that hospitals follow up with patients who received any injectable drugs from NECC, we are reviewing our medical records to determine which patients have received the injectable epidural," Pardo wrote in an email. "We will then contact those patients."

FDA said Monday that it had identified one patient with possible meningitis potentially associated with an epidural injection of triamcinolone acetonide made by the pharmacy. The drug is a steroid medication that's similar to the one previously linked to the outbreak.

In addition, FDA said a heart transplant patient came down with an infection after receiving cardioplegic solution made by the pharmacy. The solution is used to induce cardiac muscle paralysis during open-heart surgery to prevent injury to the heart.

Danila said about 5 percent of all heart transplant patients come down with the infection identified by the FDA. In a statement Monday, FDA said "there may be other explanations" for the patient's infection.

"At this point in FDA's investigation, the sterility of any injectable drugs ... and cardioplegic solutions produced by NECC are of significant concern," the agency said.

It also warned of a risk with the pharmacy's ophthalmic drugs used in conjunction with eye surgery.

While the agency's guidance affects a much larger group of clinics, Danila said the risk to patients with the new warning is less clear.

"There's no direct connection here" between the illnesses reported Monday and the additional medications from the compounding pharmacy, Danila said. "It's all speculation."

Compounding pharmacies mix ingredients to make medications when commercially manufactured drugs aren't available or aren't a good fit for patients. In Minnesota, New England Compounding Center was licensed to manufacture medications for individual patients but not to distribute larger batches for general use in clinics, said Cody Wiberg, executive director of the Minnesota Board of Pharmacy.

In a statement Tuesday, Medical Advanced Pain Specialists -- one of the two clinics in Minnesota that received the implicated steroid -- said it received medications from NECC in batches.

Pardo of Gillette Children's did not say Tuesday whether her hospital bought medications in bulk from NECC, or one-at-a-time for individual patients.

Fairview purchased cardioplegic solution from NECC due to a nationwide shortage of the medication, said Davenport, the health system's spokesman.